Developing World Setting Research Articles

Control of Very-Large Scale Irrigation Networks: A CPS Approach in a Developing-World Setting

AbstractMany developing countries face severe water shortages, a large magnitude of which can be attributed to the inefficient operation of their water networks. In this paper, we study this issue from the point of view of implementing a cyber physical systems (CPS) infrastructure, in which networked embedded controllers can be used for local control of a very large-scale canal network. We take inspiration from existing literature and report on the suitability (or otherwise) of existing methods in a third world setting. We describe partial differential equation (PDE) models for open channel flows, system identification techniques to simplify the model, local control system design and strategies to implement a decentralized control network. The theoretical study is supported by simulations on large networks.

Pneumonia in the developed world

In this paper, we review the literature on the management of pneumonia in the developed world setting. Pneumonia is usually diagnosed on the basis of a cough, respiratory distress, a fever, and chest X-ray changes. Pneumonia affects all paediatric age groups, though the highest incidence is in the under 5s. There is a significant burden of primary and secondary care illness, although mortality is low. Inpatient admission rates for pneumonia may have increased in recent years in some regions. Pneumonia is unlikely if a child presents with solely wheeze. In routine clinical practice, a microbiological diagnosis is often not made, because current tests are insensitive. Aetiology varies with geographical location, but approximately half of cases are viral. The mainstay of management of moderate pneumonia (the commonest group presenting to secondary care) is careful assessment, and oral antibiotics, followed by early discharge when the patient shows signs of improvement. We summarise the available clinical trial data from the developed world; most of these trials are not adequately powered. Patients with moderately severe pneumonia do not require invasive investigation, but clinical judgement should be used to identify and investigate more complex cases. We discuss several pathogens that have gained importance as causal agents, including non-vaccinated strains of S. pneumoniae, Panton Valentine leucocidin S. aureus, H1N1 Influenza A and Human Bocavirus. The importance of antimicrobial resistance is considered, and we review recent data on long term effects of pneumonia in childhood. By reviewing the available literature, we demonstrate that there are clear evidence gaps, and we suggest future areas for clinical research.

Antiretroviral Treatment of Adult HIV Infection

Recent data regarding the consequences of untreated human immunodeficiency virus (HIV) infection and the expansion of treatment choices for antiretroviral-naive and antiretroviral-experienced patients warrant an update of the International AIDS Society-USA guidelines for the use of antiretroviral therapy in adults with HIV infection. To provide updated recommendations for management of HIV-infected adults, using antiretroviral drugs and laboratory monitoring tools available in the international, developed-world setting. This report provides guidelines for when to initiate antiretroviral therapy, selection of appropriate initial regimens, patient monitoring, when to change therapy, and what regimens to use when changing. A panel with expertise in HIV research and clinical care reviewed relevant data published or presented at selected scientific conferences since the last panel report through April 2010. Data were identified through a PubMed search, review of scientific conference abstracts, and requests to antiretroviral drug manufacturers for updated clinical trials and adverse event data. New evidence was reviewed by the panel. Recommendations were drafted by section writing committees and reviewed and edited by the entire panel. The quality and strength of the evidence were rated and recommendations were made by full panel consensus. Patient readiness for treatment should be confirmed before initiation of antiretroviral treatment. Therapy is recommended for asymptomatic patients with a CD4 cell count < or = 500/microL, for all symptomatic patients, and those with specific conditions and comorbidities. Therapy should be considered for asymptomatic patients with CD4 cell count > 500/microL. Components of the initial and subsequent regimens must be individualized, particularly in the context of concurrent conditions. Patients receiving antiretroviral treatment should be monitored regularly; treatment failure should be detected and managed early, with the goal of therapy, even in heavily pretreated patients, being HIV-1 RNA suppression below commercially available assay quantification limits.

Emergency Medicine in the Developing World: A Delphi Study

Emergency medicine (EM) as a specialty has developed rapidly in the western world, but remains largely immature in developing nations. There is an urgent need for emergency services, but no clear guidelines are available on the priorities for establishing EM in the developing world. This study seeks to establish consensus on key areas of EM development in developing world settings, with respect to scope of EM, staffing needs, training requirements, and research priorities. A three-round Delphi study was conducted via e-mail. A panel was convened of 50 EM specialists or equivalent, with experience in or interest in EM in the developing world. In the first round, panelists provided free-text statements on scope, staffing, training, and research priorities for EM in the developing world. A five-point Likert scale was used to rate agreement with the statements in Rounds 2 and 3. Consensus statements are presented as a series of synopsis statements for each of the four major themes. A total of 168 of 208 statements (81%) had reached consensus at the end of the study. Key areas in which consensus was reached included EM being a specialist-driven service, with substantial role for nonphysicians. International training courses should be adapted to local needs. EM research in developing countries should be clinically driven and focus on local issues of importance. The scope and function of EM and relationships with other specialties are defined. Unambiguous principles are laid out for the development of the specialty in developing world environments. The next step required in this process is translation into practical guidelines for the development of EM in developing world settings where they may be used to drive policy, protocols, and research.

Lack of Minority K65R-Resistant Viral Populations Detected After Repeated Treatment Interruptions of Tenofovir/Zidovudine and Lamivudine in a Resource-Limited Setting

Lack of Minority K65R-Resistant Viral Populations Detected After Repeated Treatment Interruptions of Tenofovir/Zidovudine and Lamivudine in a Resource-Limited Setting

Long-term outcome of surgically managed necrotizing enterocolitis in a developing country

Necrotizing enterocolitis (NEC) is a serious condition with a high morbidity and mortality commonly affecting premature babies. Data for the impact of the long-term disease burden in developing countries are limited although poor long-term outcome of surgically managed patients has been shown in terms of increased risk of neurodevelopmental delay, increased infectious disease burden and abnormal neurological outcomes in the developed world. To evaluate the long-term outcome of a pre-human immunodeficiency virus pandemic NEC cohort to characterize common risk factors and outcome in a developing world setting. A retrospective review of medical records was carried out on a cohort of 128 premature neonates with surgical NEC (1992-1995). Morbidity, mortality and long-term outcome were evaluated. Data for 119 of 128 sequentially managed neonates with surgically treated NEC was available. Mean gestational age was 32 weeks and average birth weight was 1,413 g. Early (30-day postoperative) survival was 69% (n = 82) overall and 71% in the <1,500 g birth weight group (n = 68; 53%). Overwhelming sepsis (n = 16) or pan-intestinal necrosis (n = 18) accounted for most of the early deaths. Late deaths (>30 days postoperatively, n = 22) resulted from short bowel syndrome (5), sepsis (9), intraventricular hemorrhage (1) and undetermined causes (7). On follow-up (mean follow-up 39 months, 30 for >2 years), long-term mortality increased to 50%. Late surgical complications included late colonic strictures (9), incisional hernias (2) and adhesive bowel obstruction (3). Fifteen patients had short bowel syndrome, of which 10 (66%) survived. Of the long-term survivors, 8 (20%) had severe neurological deficits and 20 (49%) had significant neurodevelopmental delay. Neurological deficits included severe auditory impairment [5 (12%)] and visual impairment [4 (10%)]. Recurrent infections and gastrointestinal tract complaints requiring hospital admission occurred in 16 (39%) of survivors. Necrotizing enterocolitis in premature infants impacts morbidity and mortality considerably. A number do well in a developing country, but septic complications may be ongoing and recurrent. The high risk of neurodevelopmental and other problems continue beyond the neonatal period and patients should be "flagged" on for careful follow-up.

Causes and management of diarrhoea in children in a clinical setting

Diarrhoeal disease and its complications remain a major cause of morbidity and mortality in children, especially in developing countries. Diarrhoea is characterised by an increased frequency and volume, and decreased consistency of stool from the norm. Pathogens vary between developed and developing world settings. Rotavirus diarrhoea is the most important aetiological agent implicated in severe dehydrating diarrhoea. Although it is important to recognise the specific microbiological causation of diarrhoea in order to target appropriate treatment, the broader preventive aspects put forward by the World Health Organization (WHO) indicate the fundamental contributors to the massive burden of disease in developing countries. The management of a child presenting with acute diarrhoea must include a thorough history and examination with evaluation of hydration status, nutritional status and comprehensive clinical evaluation for any complications or associated illnesses. The most recent advances in the area of acute diarrhoeal disease include zinc supplementation, reduced osmolarity oral rehydration solution (ORS) and rotavirus vaccination.

Waste reduction strategies for improved management of household solid waste in Jamaica

Three waste reduction strategies were studied by a survey in the St. Ann's Parish located in the small-island developing nation of Jamaica. Factors designated as incentives to waste reduction existed primarily at the household level, specifically waste segregation, household education, environmental concern and knowledge; whereas, the barriers existed primarily at the national or regional levels, namely government policies and finances. The greatest potential for initiating waste reduction strategies and diverting waste from a landfill in this developing world setting is thus within the household, specifically by community-based waste reduction initiatives that build upon already-existing practices and improve local solid waste management.

Treating Uveitis in the Developing World Setting

Treating Uveitis in the Developing World Setting

Nurse education in a resource limited environment: An evaluation of an educational teaching package on intramuscular injections, in Blantyre, Malawi

This paper describes the implementation and evaluation of a pilot nursing education package of best practice guidelines involving intramuscular injections in a developing world setting. We briefly examine what is known about intramuscular injection techniques through reviewing the evidence on the topic, and disseminate best practice guidelines, in order to update and improve nursing technique in the paediatric departments of The Queen Elizabeth Central Hospital. A teaching package of safe intramuscular injection techniques was implemented in October/November 2008. All paediatric wards were involved, and consisted of a 30 min structured package, with theory and then practical sessions. The effectiveness of the intervention was evaluated by a knowledge based questionnaires and non-participant observations of intramuscular injections taking place, to see if new techniques were being used. Theory based learning tested was at a high level and showed the nurses had a good scientific and evidence based understanding for their practice change. A convenience sample of 223 intramuscular injections was observed over December and January. Overall 188 (84.3%) took place in the thigh, the remainder in other locations. Theory with practical teaching can have an impact upon the care given, possibly reducing the complications associated with intramuscular injections. Further plans include ensuring sustainability of the programme and extension of the project to other developing countries.

Use of GlideScope Ranger in the management of a child with Treacher Collins syndrome in a developing world setting

Use of GlideScope Ranger in the management of a child with Treacher Collins syndrome in a developing world setting

Lowbury Lecture 2008: infection control and limited resources – searching for the best solutions

Healthcare-associated infections constitute an important public health problem in both developing and transitional countries. Despite considerable progress in the development of infection control programmes in some countries with limited resources, programmes in most developing world settings are non-existent, or are not implemented. Kosova, the poorest country in Europe, illustrates the challenges posed by infection control in the developing world. In many hospitals activities are limited by the lack of financial resources, poor infrastructure, overcrowding, inadequate hygiene, poorly functioning laboratory services, poor management, insufficient technology and a shortage of trained staff. Infection control guidelines from developed countries are often perceived as a standard for the developing world, but have to be modified to take into account differences in local needs. The best solutions entail greater governmental commitment and application of infection control procedures consistent with available resources. The International Nosocomial Infection Control Consortium (INICC) plays an important role in these activities in developing countries.

'It won't happen to me': the knowledge-attitude nexus in adolescent smoking

Behavioral models state that adolescents need not only to know about the dangers of smoking, but also to perceive themselves as susceptible to those dangers prior to modifying their smoking behavior. However, this hypothesis has not been tested in developing world settings where the context of tobacco use may differ. Survey data were collected from a sample of 1294 adolescents 13-20 years of age--from three under-privileged suburbs of Beirut, Lebanon. Scores were calculated to measure the knowledge of and the perceived susceptibility by a series of statements related to the consequences of tobacco use. Bivariate and multivariate methods were used to assess the association of knowledge and perceived susceptibility with smoking, controlling for socio-demographic variables. A logistic regression model showed that the odds of ever smoking among adolescents who had less knowledge of smoking were 1.9 times those of adolescents with more knowledge. Similar odds were demonstrated for adolescents who did not perceive themselves susceptible to smoking hazards compared with those who did. These results suggest that awareness campaigns should focus on raising the perceived susceptibility of adolescents by including items that are more within the realm of an adolescent's frame of mind such as smelly clothes and discolored teeth.

The UCB particle monitor: A tool for logging frequency of smoking and the intensity of second-hand smoke concentrations in the home

Second-hand tobacco smoke (SHS) exposure generates a large public health burden. Recent legislation has moved to prohibit smoking in public places and there are concerns that this may lead to an increase in exposures in private homes. Measurement of SHS aerosol has tended to use active pumped samples or longer-term diffusive badges. Pumped methods are noisy and poorly tolerated in home settings while diffusive badges do not provide real-time data. The UCB particle monitor (UCB-PM) is a modified smoke-alarm device capable of logging changes in airborne particulate matter over extended periods and has been used successfully to measure biomass fuel smoke concentrations in developing world settings This study has examined the use of the UCB-PM to measure SHS aerosol in both controlled laboratory conditions and a pilot field trial over a 7 day period in a smoker's home. Comparisons with a pumped sampler (TSI Sidepak Personal Aerosol Monitor) indicate good agreement over a range of exposure concentrations but there is evidence of a threshold effect at approximately 0.5 mg/m3 of fine particulate measured as PM2.5. While this threshold effect undermines the ability of the device to provide useful data on the time-weighted average SHS concentration, the field trial indicates that that the UCB-PM has a sensitivity of about 71% and a specificity of 98%. The device has many advantages including zero noise operation, low cost and long battery life and may be a useful tool in quitting and smoke-free home intervention studies.

Training Pediatric Clinical Pharmacology and Therapeutics Specialists of the Future

In recent years there has been a rapid and marked increase in global recognition of the need for better medicines for children, with various initiatives being implemented at global and regional levels. These exciting developments are matched by recognition of the need to build greater capacity in the field of pediatric clinical pharmacology and therapeutics to help deliver on the promise of better medicines for children. A range of pediatric medicines researchers, educators, clinical therapeutics practitioners, and experts in drug evaluation, regulation, and broader medicines policy are needed on a larger scale, in both developed and developing world settings. The current and likely future training needs to meet these diverse challenges, the current realities of trying to meet such needs, and the opportunities for international networking to help meet future training needs are discussed from a global perspective.

Harnessing Pharmacogenomics to Tackle Resistance to the “Nucleoside Reverse Trancripatse Inhibitor” Backbone of Highly Active Antiretroviral Therapy in Resource Limited Settings

BackgroundThe sustainable use of HAART within the sub-Saharan and other developing world settings faces the emerging challenge of drug resistance. Nucleoside reverse transcriptase inhibitors (NRTI) form the backbone of HAART and preserving their “antiviral efficacy” is thus critical to sustainable HAART use.MethodsA systematic review of the “mechanisms of evolution” of resistance to NRTI at the HIV genome level, and the phenotypic manifestations on drug pharmacokinetics was done.ConclusionThis paper provides an evidence based account of how the knowledge of pharmacogenomics may be exploited to tackle NRTI resistance within limited resource.

Silently lost in a sea of infections.

This article highlights some of the problems faced in working in resource poor settings. While the situation may differ from general practice in London, many of the same principles apply.It highlights the importance of keeping hearing loss in mind when seeing children with other conditions.It shows some of the principles in the Alma Ata declaration, such as the inequity in treatment between developed and developing world settings, health care rationing and the concept of health including social well-being. This article relates to my time working in Pakistani Kashmir for a medical NGO in both primary and secondary care paediatrics. It describes trying to help a young girl with hearing loss. Particularly in a setting like this, you tend to prioritise the immediate problems (mostly infections in infants) and ignore other things however difficult they may be for the child and family. Most importantly I feel this article provides a different perspective, giving a first hand account of dealing with a difficult problem in a difficult setting. While not directly related to general practice in London, this article provides many important and relevant messages. Neonatal hearing screening may mean that congenital hearing loss is picked up at birth, but other forms will present at a later stage and children who have not been screened (who missed the screening, parental refusal and those who came from overseas) still need to be considered. Thirty years on from the Alma Ata conference the world is still blighted by many of the same problems. This personal account shows many of the difficulties spelt out by the declaration. In particular it highlights the persisting inequity in treatment between the developed and developing world. It shows the importance of health including social well-being. The girl in this story lacked a disease, but being unable to hear, or more importantly communicate, would mean an inability to live an independent life in the future. Another concept highlighted is health rationing, which is faced almost daily in any field of medicine. This is especially so in fragile states and war zones. External health funding goes predominantly to 'fashionable' diseases such as HIV, which has lead to organisations trying to promote the 'neglected' diseases, for example trypanosomiasis. Despite its debilitating effects hearing loss achieves even less attention than these.

Pedestrian Road Traffic Injuries in Urban Peruvian Children and Adolescents: Case Control Analyses of Personal and Environmental Risk Factors

BackgroundChild pedestrian road traffic injuries (RTIs) are an important cause of death and disability in poorer nations, however RTI prevention strategies in those countries largely draw upon studies conducted in wealthier countries. This research investigated personal and environmental risk factors for child pedestrian RTIs relevant to an urban, developing world setting.MethodsThis is a case control study of personal and environmental risk factors for child pedestrian RTIs in San Juan de Miraflores, Lima, Perú. The analysis of personal risk factors included 100 cases of serious pedestrian RTIs and 200 age and gender matched controls. Demographic, socioeconomic, and injury data were collected. The environmental risk factor study evaluated vehicle and pedestrian movement and infrastructure at the sites in which 40 of the above case RTIs occurred and 80 control sites.FindingsAfter adjustment, factors associated with increased risk of child pedestrian RTIs included high vehicle volume (OR 7·88, 95%CI 1·97–31·52), absent lane demarcations (OR 6·59, 95% CI 1·65–26·26), high vehicle speed (OR 5·35, 95%CI 1·55–18·54), high street vendor density (OR 1·25, 95%CI 1·01–1·55), and more children living in the home (OR 1·25, 95%CI 1·00–1·56). Protective factors included more hours/day spent in school (OR 0·52, 95%CI 0·33–0·82) and years of family residence in the same home (OR 0·97, 95%CI 0·95–0·99).ConclusionReducing traffic volumes and speeds, limiting the number of street vendors on a given stretch of road, and improving lane demarcation should be evaluated as components of child pedestrian RTI interventions in poorer countries.

Development of an ultrasound training curriculum in a limited resource international setting: successes and challenges of ultrasound training in rural Rwanda

BackgroundOver the last decade, the diffusion of ultrasound technology to nontraditional users has been rapid and far-reaching. Much research and effort has been focused on developing an ultrasound curriculum and training and practice guidelines for these users. The potential for this diagnostic tool is not limited to the developed world and in many respects ultrasound is adaptable to limited resource international settings. However, needs-based curriculum development, training guidelines, impact on resource utilization, and sustainability are not well studied in the developing world setting.AimsWe review one method of introducing applicable curriculum, training local providers, and sustaining a comprehensive ultrasound program.MethodsTwo rural Rwandan hospitals affiliated with a US nongovernmental organization participated in a pilot ultrasound training program. Prior to introduction of ultrasound, local physicians completed a survey to determine the perceived importance of various ultrasound scan types. Hospital records were also reviewed to determine disease and presenting complaint prevalence as part of an initial needs assessment and to define our curriculum. We hypothesized certain studies would be more utilized and have a greater impact given available treatment resources.ResultsWe review here the choice of curriculum, the training plan, helpful equipment specifications, and implementation of ongoing measures of quality assessment and sustainability. Our 9-week lecture and practice-based ultrasound curriculum included obstetrics, abdominal, renal, hepatobiliary, cardiac, pleural, vascular, and procedural ultrasound.ConclusionsWhile ultrasound as a diagnostic modality for resource-poor parts of the world has generated interest for years, recent advances in technology have brought ultrasound again to the forefront as a sustainable and high impact technology for resource-poor developing world nations. From our experience in rural Rwanda, we conclude that ultrasound remains helpful in patient care and the diagnostic impact is enhanced by choosing the correct applications to implement. We also conclude that ultrasound is a teachable skill, with a several week intensive training period involving hands-on practice skills and plans for long-term learning and have begun a second phase of evaluating knowledge retention for this introductory program.

Predictors of postnatal depression in an urban South African cohort

Background Postnatal depression can have a significant impact on both maternal and child health. There have been very few studies undertaken in the developing world to identify women at risk of postnatal depression. The present study aimed to investigate risk factors for the occurrence of postnatal depression in urban South African women. Method A large prospective population cohort study identified antenatal risk factors for postnatal depression in Soweto, Johannesburg, South Africa. One thousand and thirty-five women were interviewed in the antenatal period and subsequently completed the Pitt Depression Questionnaire in the postnatal period. Results 170/1035 (16.4%) women were probable cases of postnatal depression. The strongest independent predictors of postnatal depression were exposure to extreme societal stressors (witnessing a violent crime/danger of being killed) (adjusted Odds Ratio 2.468 (95% Confidence Interval 1.509, 4.037)) and reporting difficulties with their partner (adjusted OR 1.645 (1.088, 2.488)). Limitations There was some loss of the sample during follow-up (35.1%), which was to be expected given the turbulent nature of the study setting. The measures were questionnaires administered by interview. Conclusion Postnatal depression is common in women in developing world settings, such as this part of Southern Africa. Although some of the risk factors for postnatal depression were similar to those identified in studies in developed nations, some important differences exist, most notably antenatal exposure to extreme societal stressors. This study shows that it is possible to identify women at risk during pregnancy in a developing world setting.